I have always been a little surprised to find that consultation models aren’t widely taught in Australian general practice. I always found it quite useful to have a range of ways of looking at the complex interactions between myself and the patient, ways of getting myself unstuck when a purely medical approach didn’t seem to be paying dividends.
I’m not sure why the models haven’t caught on in Australia. It may be that they don’t take root in a medical system that prizes procedures over cognition. GPs here are a proud bunch, often under-appreciated by specialist colleagues and politicians alike. Consultation models are easily dismissed as an impractical academic distraction, whether they are based on psychoanalysis, or are a list of a thousand micro-tasks.
And yet, I still think it’s useful to have something to provide direction when we are a bit stuck. If we’re not sure what to do, we can remind ourselves that there are two tasks that can be applied to every single consultation we do.
TASK 1: MAKE SURE THE PATIENT DOESN’T DIE IN THE CAR PARK
It’s not hard to see the importance of this. It’s safe to say we’re not doing our job properly if, whatever else we do, we send our patient away with a heart attack, or fail to recognise their coffee-ground vomit.
Yes, it can be hard to recognise meningitis early on, but we are the specialists in early diagnosis, and, if you’re happy they are not going to die in the car park, you can always use Task 2 to ensure the patient is OK.
TASK 2: GIVE THEM A REASON TO COME BACK
There are many ways of doing this. We might order investigations so that people come back for the results. We could issue prescriptions without repeats, so people need to see us again for another prescription. We could simply rebook them an appointment before they leave. However, these methods may not work every time.
There may be no rational reason to investigate (though I wonder how many vitamin D requests are done simply to bring people back), and many people don’t continue their medications even with a prescription.
Of course, the most effective way to ensure people come back is to develop rapport — to listen to their story, to take them seriously, to understand their situation and the worries. We can stop a patient in their tracks by praising their efforts because they are so used to being berated for their diet and lack of understanding of the health system. Unlike emergency departments we want them to come back.
It’s in those repeat visits where we can continue a conversation about smoking, develop the trust to be told about their suicidal thoughts, keep answering questions that come up about living with rheumatoid arthritis. We can also allow time to reveal its diagnostic secrets and do its therapeutic work. As soon as someone stops coming back, that’s game over for preventive health conversations.
You know all this already, gentle reader. But sometimes, amid the complex bustle of people’s illnesses and worries, it’s easy to lose our way in wondering where to go next. And a quick reminder that we don‘t need to solve everything today might be how we become unstuck.
Of course, a successful day is where no one died in the car park.
- © British Journal of General Practice 2018